Triage and Respiratory

Emergency
Marshell Tendean, MD DPCP
Department of Intenal Medicine
UKRIDA Jakarta
Objective :

To discuss about triage and clinnical approach in emergency situations

To Discuss about Severe Asthma :
Epidemiology
Approach to diagnosis
Treatment
To discuss about acute respiratory distress syndrome (ARDS) :
Epidemiology
Approach to diagnosis
Treatment
Prognosis
Triage

The sorting of patients into priority groups according to their need

and the resources available

Emergency
P priority
Q Queue (non urgent)
Emergency Case :

Emergency
Urgent
False emergency
Death
Surgery
Approach to patients in Emergency situation

Do brief history taking.

Important data to ask :

Trauma / non trauma
Surgical / non surgical
Intoxication / toxin
Do things promptly!!
Primary survey : Secondary survey :
A: Airway
Complete anamnesis
B: Breathing
Comprehensive phyrsical
C: Circulation
examination
D: Disability
Extensive ancilary
E: Environment
procedures
Definitive treatment
Severe asthma
Severe asthma

Definition of severe asthma

Asthma which requires treatment with high dose inhaled

corticosteroids (ICS) plus a second controller (and/or systemic CS)
to prevent it from becoming uncontrolled or which remains
uncontrolled despite this therapy.

Its prevalent among 5-10% of overall ashtma patients

International ERS/ATS Guidelines on Definition,

Evaluation, and
Treatment of Severe Asthma 2013
 The term difficult asthma is reserved for asthma that remains uncontrolled despite the prescription of

high-intensity asthma treatment due to:

Persistently poor compliance

Psychosocial factors, dysfunctional breathing, vocal cord dysfunction;

Persistent environmental exposure to allergens or toxic substances;

Untreated or undertreated comorbidities such as chronic rhinosinusitis, reflux disease or obstructive sleep apnoea syndrome.

The term severe refractory asthma should be reserved for patients with asthma in whom alternative

diagnoses have been excluded, comorbidities have been treated, trigger factors have been removed (if

possible) and compliance with treatment has been checked, but still have poor asthma control or frequent

(>2) severe exacerbations per year despite the prescription of high-intensity treatment.
Natural history and risk factors
The severe asthma phenotypes are related to genetic factors, age of asthma
onset, disease duration, exacerbations, sinus disease and inflammatory
characteristics
Early childhood-onset asthma (over a range of severity) is characterized by allergic
sensitization, a strong family history and more recently, non-allergy/atopy related
genetic factors.

Late-onset, often severe asthma is associated with female gender, reduced pulmonary
function despite shorter disease duration, and in some subgroups, a strong association
with persistent eosinophilic inflammation, nasal polyps and sinusitis and often aspirin
sensitivity and respiratory tract infections, but less support for specific genetic factors.
Pathogenesis :

Risk factors : occupational, obesity, smoke and environmental air

polution
Epigenetics and genetics (IL-4, IL-6 pathways)
Inflamation and adaptive imunity
Respiratory infections
Activation of innate immunity pathways
Structural abnormalities
Approach to diagnosis :

Step 1. Determining that the patient has asthma

Recommendation 1

In children and adults with severe asthma without specific indications

for chest HRCT based on history, symptoms and/or results of prior
investigations we suggest that a chest HRCT only be done when the
presentation is atypical (conditional recommendation, very low quality
evidence).
Thorax 2011;66:910e917
 Step 2. Assessing Co-morbidities and Contributory Factors
Rhinosinusitis/(adults) nasal polyps

Psychological factors: Personality trait, symptom perception, anxiety, depression

Vocal cord dysfunction

Obesity

Smoking/smoking related disease

Obstructive sleep apnea

Hyperventilation syndrome

Hormonal influences: Premenstrual, menarche, menopause, thyroid disorders

Gastroesophageal reflux disease (symptomatic)

Drugs: Aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), -adrenergic blockers, angiotensin converting enzyme inhibitors
(ACE-inhibitors)
Condition mimicking severe asthma.
 Step 3. Approaches to Asthma Phenotyping
Step 4. Therapy
Established therapies

Recently-developed therapies and

Future approaches that will require phenotypic characterisation

ER Assesment :

Young & Salzman : pp. 1319,

24
ER Assesment
Status asthmaticus is an asthma exacerbation that is refractory to or does not significantly
improve with initial treat ment and requires escalation of treatment, usually leading to
hospital admission

CHEST 2004; 125:10811102

ER Assesment

The patient should be hospitalized if, he or she still has significant

wheezing, accessory muscle use, permanent requirement for oxygen
to maintain Spo2 92%, and a persistent reduction in lung function
(FEV1 or PEF 40% of predicted) The presence of factors indicating
high risk of asthma- related death (inadequate access to medical
care and medications, difficult home conditions, and difficult- to-
obtain transport to hospital in the event of further deterioration).
If a patient is free of symptoms, and has lung functions (FEV1 or
PEFR) 60 of predicted, the patient can be dis- charged unless other
mitigating circumstances exist.
ER Assesment :

Patients with findings of severe airflow obstruction (use of

accessory muscles of respiration, PP >12 mm Hg, diaphoresis,
inability to recline, hypercapnia, or PEFR < 40% of predicted) who
demonstrate a poor response to initial therapy (less than 10%
increase in PEFR) or who deteriorate despite therapy should be
promptly admitted to an intensive care unit.
Other indications for immediate admission to an intensive care
unit include respiratory arrest, an altered mental status, and
cardiac toxicity (tachyarrhythmias, angina, or myocardial
infarction).

Young & Salzman : pp. 1319, 24

ICU Admission :

NIPV
Intubation
Sedative during intubation
Phenothypic targeted therapy for severe
asthma
Complications of severe asthma

Pneumothorax
Pneumomediastinum
Subcutaneous emphysema
Pneumopericardium
Myocardial infarction
Mucus plugging
Atelectasis
Theophylline toxicity
Electrolyte disturbances (hypokalemia, hypophosphatemia, hypomagnesemia)
Myopathy
Lactic acidosis
Anoxic brain injury
Acute Respiratory
Distress Syndrome
ARDS

Definition :
An Acute onset; ratio of partial pressure of arterial oxygen to frac tion of
inspired oxygen (PaO2/FiO2) of 200 or less, regardless of positive end
expiratory pressure; bilateral in ltrates seen on fron tal chest radiograph;
and pulmonary artery wedge pressure of 18 mm Hg or less when measured,
or no clinical evidence of left atrial hypertension.

Am Fam Physician. 2012;85(4):352-358

Most cases of ARDS in adults
are associated with pulmonary
sepsis (46 percent) or
nonpulmonary sepsis (33
percent)
We often deny myself for my
calling
But in my missery
We will call and tell save 1 more
lives
Save 1 more lives